Provider Demographics
NPI:1740526748
Name:ROBERTS, BENJAMIN STANLEY (DO)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:STANLEY
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25150 HANCOCK AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562
Mailing Address - Country:US
Mailing Address - Phone:951-698-8222
Mailing Address - Fax:951-698-7411
Practice Address - Street 1:25150 HANCOCK AVE STE 204
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5989
Practice Address - Country:US
Practice Address - Phone:951-698-8222
Practice Address - Fax:951-698-7411
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A15422207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program